Note: This Form Should Be Completed by the Student in Close Consultation with the Mentor

EXP+ Contract

Students may fulfill the Stony Brook Curriculum's EXP+ learning objectives through a mentored learning activity in which the student applies knowledge and skills acquired within the classroom in real-world settings and in which insights and skills developed through real-world experience enhance academic success and professional development. Successful experiential learning requires reflection, mentoring, feedback, critical analysis and synthesis.

Note: This form should be completed by the student in close consultation with the mentor and/or supervisor.

Student name______ID#______

Student email______Sponsor/Mentor______

Course #______Section#______Year______

Sem: Fa___ Sp___ Sum1___ Sum 2___

Credit hours requested______(1 credit hour = 40 hours effort/sem)

Prerequisitescompleted (if applicable)______

What additional training (if any) must student complete prior to enrollment?______

Project Description: In 1-3 paragraphs describe the proposed research project, internship, or other learning experience.

Responsibilities and Structure:How many hours/week will you work? Who will be your primary on-site supervisor/mentor? Describe your responsibilities.

Learning Objectives: What skills/knowledge do you hope to gain from this experience? Check all that apply; describe briefly.

___develop problem solving skills______

___work independently, setting goals and managing time______

___work effectively with a team______

___develop communication skills______

___improve knowledge of your discipline and/or future profession______

___acquire discipline-specific skills (e.g., computer, research skills):______

___other:______

Goals:

1)How do you expect this activity will contribute to your development--academic, professional, intellectual, other?

2)How do youexpect to contribute to the goals of the organization or project?

Reflection: Describe the specific forms in which you will reflect upon and record what you are learning.

1)During the activity: How will you record what you are doingand reflect upon what you are learning?
(e.g., lab notebooks, journal, blog, emails to academic mentor)

2)At the end of the activity: How will you synthesize/present outcomes and reflect upon what you have learned? (Final reflection may take the form of a paper, a presentation, or another substantial product that addresses: the skills developed;relevance to your academic studies; insights that changed/confirmed your future professional goals, etc.)

Monitoring: How will the academic mentor (and on-site supervisor if applicable) provide feedback?

1) During the activity?

2) At the end of the activity?

Student Information: / Undergraduate Program Director Information:
Signature______Date:______/ Signature______Date:______
Name (please print): ______/ Name (please print): ______
Academic Mentor/Supervisor Information: / Site Supervisor Information:
Signature______Date:______/ Signature______Date:______
Name (please print): ______/ Name (please print): ______
Title: ______/ Title: ______
Department: ______/ Company: ______
Phone: ______/ Phone: ______
Email: ______/ Email: ______

Note: Submit the completed form with signatures and supporting materials to the UG Director or Coordinator.